While in the middle of a therapy session a patient who is opening up his soul to a therapist might wonder from time to time wonder, what is my therapist thinking about me?
The question is rather general. We might do better by asking, how does a therapist think in responding to what a patient says?
Let's first make the assumption that the patient is in the hands of a good therapist. Defining a 'good therapist,' is something that has written about a good deal in mental health literature. Its commonly held that regardless of the 'school' that a therapist allies with, there seem to be common characteristics that are a part of being an effective counselor. Not surprisingly, traits that seem to be shared amongst the better ones are: good instinctive social skills, the capacity to empathize, and a degree of disciplined training. All in all, the findings coming out of research like this have led to pretty common sense conclusions.
So, given you have what you deserve, a good therapist, how is he thinking?
Most of the time as we therapists are quietly listening to our patients we are forming tentative hypotheses and asking ourselves, is there anything I can say at this moment that will be useful to my patient?
Say someone is experiencing intense grief. As the therapist listens he might hear inferences, at a particular moment, that a part of his patient's pain is related to practical logistics around the loss of their beloved. The patient might be financially dependent on his partner, or has never managed running the household. If the therapist senses that there are practicalities of living in the subtext of the patient's expression of grief, he might direct the patient's focus for a time onto some of these issues. They then both begin to problem solve for a time. At other times a therapist might notice that there are unconscious feelings near the surface, such as anger toward the deceased. If the therapist judges that the patient is ready to be confronted with an unacknowledged feeling he might speak up. At other times it might be untimely to make such an interpretation and the therapist will hold his tongue.
Listening for subtext in the narratives of our is always important, but the challenge for the therapist goes beyond developing theories of what is behind the patient's narrative. The challenge also includes having a feel for the timeliness of when it will be most constructive to make an interpretation.
Timing means that a patient is ready to listen and integrate what the therapist has to say. The most accurate observation might be awkward and destructive if presented in an inopportune time.
Imagine the therapist is dealing with a prideful narcissist, an individual who essentially is an emperor without clothes. Picture a setting in which therapist and patient are just starting out and little in the way of trust and a sense of alliance has yet been established. Would a therapist really want to address the patient's insecurity in such an early context even if his insight were spot on? Likely not, it could fracture the alliance. But with time an alliance might be formed where the patient has enough trust and insight to tolerate such a confrontation. Imagine the patient has progressed to the point that he is beginning to acknowledge his lack of self confidence. At such a time it would be beneficial for the patient to be made aware of the connection between his bluster and lack of security.
Sometimes a patient will wonder, does my therapist like me? One can say that when the treatment is going well, that is, when the treatment is occurring with sufficient trust and accuracy that the patient is revealing himself in a genuine way, the answer is yes. On the other hand, when the therapist feels a sense of dislike, he will see this is a signal that there is something that is not genuine that is clouding the picture. In truth, humans are inherently beautiful when their essential self is visible.
Finally, rest assured that a good therapist will feel a sense of privilege in being able to work with his patient. Patient's stories as a collective constitute the work contained within the greatest library on the planet, the library of human experience. Therapists are lucky to have access to such a hallowed place.